Healthcare Provider Details

I. General information

NPI: 1588896427
Provider Name (Legal Business Name): JANE LIU PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 9TH ST
PORT ST JOE FL
32456
US

IV. Provider business mailing address

1121 BLAZING STAR ST
PANAMA CITY FL
32405-2788
US

V. Phone/Fax

Practice location:
  • Phone: 850-229-8244
  • Fax:
Mailing address:
  • Phone: 414-791-5979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: